Tuesday, September 24, 2013

Narrow Networks - Some customers of the new insurance exchanges may be surprised at the "narrow network" included in their insurance coverage.

Narrow networks have a limited list of approved provider and will likely make out-of-network treatment difficult if not impossible.

This is just now hitting the news, a few days before the exchanges begin operations.

Private Exchanges - The concept of health insurance exchanges is being adopted by employers looking for cheaper coverage and fewer hassles, putting employees into private exchanges managed by various consultants and facilitators.

It is too early to judge the scope of this innovation, but it could become a very large factor in employer provided health insurance.

Tuesday, September 17, 2013

Obamacare is
complicated. ACA is a very complex plan with numerous phase-ins
cluttered with multiple implementation delays.

The latest confusion
involves employer notification requirements.

The employer insurance
mandate has been DELAYED UNTIL 2014

The employer notice of the
existence of health insurance exchanges is still in place October
1, 2013.

It gets worse.

Small employers (below the
50 FTE threshold) not required to provide insurance ARE REQUIRED to
send the notices to employees on or before October 1st,
and are required to give notices to new employees with 14 days of the
start date. Large employers are also required, as they should know.

Any employer covered by the
Fair Labor Standards Act (overtime and minimum) wage is subject to
the requirement, effectively just about every employer in the
country.

The requirement will be
enforced by the U.S. Department of Labor, and although opinions vary
it is best to assume a daily penalty for failure to comply.

Thursday, August 29, 2013

The Department of Treasury has issued the final implementing regulations for the "Shared Responsibility Payments," more commonly known as the "individual mandate."http://www.ofr.gov/OFRUpload/OFRData/2013-21157_PI.pdfA quick scan reveals no surprises, a more detailed reading to follow.The mandate is controversial and the large role of the IRS in enforcing the mandate is also controversial.

October
1st
is a major implementation date for the Affordable Care Act (ACA),
often referred to as Obamacare.

On October 1st
the state health insurance exchanges will open and a new era in
health insurance begins.

There are no significant Medicare changes on
October 1st.

There
is a great deal of confusion, as evidenced by media reports, among
Medicare beneficiaries. Some of the confusion is natural,
considering the complexity of Obamacare, and some is intentional (my
own political party spreading and encouraging the misinformation).
And the con artists and scammers are using this to con the elderly.

The
ACA does not make immediate or dramatic changes to Medicare. The ACA
will make changes to Medicare, many of them in the relationship
between providers and the government, many largely irrelevant to
patients. The U.S. health care system will evolve into something
different, impacting all of us in some way or another.

There
are plenty of real problems with the design and roll out of
Obamacare, there is no need to scare senior citizens.

Friday, August 9, 2013

Obamacare is in the news every day,
with much discussion of jobs and exchanges and insurance and many
other topics. My beat is the other side, the provider side, and a
great deal of confusion and chaos lives there.

What are providers supposed to be
doing?

improve quality

cut costs

install complex EMR systems able to
link into EHR networks

work through a massive transition to
ICD-10 coding

move into a complex “big data”
environment

move to innovative delivery and revenue
models

(ACOs, bundling)

overall, develop and implement new and
unknown clinical and business models

So what's the problem?

No one, in or out of government, can
tell us what the destination is. This is a ginormous lab experiment
with patients as the white mice.

When you and the President sought our support for the Affordable Care
Act (ACA), you pledged that if we liked the health plans we have now,
we could keep them. Sadly, that promise is under threat. Right now,
unless you and the Obama Administration enact an equitable fix, the ACA
will shatter not only our hard-earned health benefits, but destroy the
foundation of the 40 hour work week that is the backbone of the American
middle class.

Like millions of other Americans, our members are front-line workers
in the American economy. We have been strong supporters of the notion
that all Americans should have access to quality, affordable health
care. We have also been strong supporters of you. In campaign after
campaign we have put boots on the ground, gone door-to-door to get out
the vote, run phone banks and raised money to secure this vision.

Now this vision has come back to haunt us.

Since the ACA was enacted, we have been bringing our deep concerns to
the Administration, seeking reasonable regulatory interpretations to
the statute that would help prevent the destruction of non-profit health
plans. As you both know first-hand, our persuasive arguments have been
disregarded and met with a stone wall by the White House and the
pertinent agencies. This is especially stinging because other
stakeholders have repeatedly received successful interpretations for
their respective grievances. Most disconcerting of course is last
week’s huge accommodation for the employer community—extending the
statutorily mandated “December 31, 2013” deadline for the employer
mandate and penalties.

Time is running out: Congress wrote this law; we voted for you. We
have a problem; you need to fix it. The unintended consequences of the
ACA are severe. Perverse incentives are already creating nightmare
scenarios:

First, the law creates an incentive for employers to keep employees’
work hours below 30 hours a week. Numerous employers have begun to cut
workers’ hours to avoid this obligation, and many of them are doing so
openly. The impact is two-fold: fewer hours means less pay while also
losing our current health benefits.Second, millions of Americans are covered by non-profit health insurance
plans like the ones in which most of our members participate. These
non-profit plans are governed jointly by unions and companies under
the Taft-Hartley Act. Our health plans have been built over decades by
working men and women. Under the ACA as interpreted by the
Administration, our employees will treated differently and not be
eligible for subsidies afforded other citizens. As such, many employees
will be relegated to second-class status and shut out of the help the
law offers to for-profit insurance plans.

And finally, even though non-profit plans like ours won’t receive the
same subsidies as for-profit plans, they’ll be taxed to pay for those
subsidies. Taken together, these restrictions will make non-profit plans
like ours unsustainable, and will undermine the health-care market of
viable alternatives to the big health insurance companies.

On behalf of the millions of working men and women we represent and
the families they support, we can no longer stand silent in the face of
elements of the Affordable Care Act that will destroy the very health
and wellbeing of our members along with millions of other hardworking
Americans.

We believe that there are common-sense corrections that can be made
within the existing statute that will allow our members to continue to
keep their current health plans and benefits just as you and the
President pledged. Unless changes are made, however, that promise is
hollow.

We continue to stand behind real health care reform, but the law as
it stands will hurt millions of Americans including the members of our
respective unions.

Monday, March 25, 2013

There is some buzz about the possibility or probability of physicians retiring early due to unhappiness with PPACA (Obamacare). Bitching and whining is hardly new for physicians, and there are plenty of people wanting to put a bad spin on Obamacare.

So
I have worked my way through a part of my national network; and have a decidedly
non-scientific survey about the buzz.

Some possible trends:

The
electronic medical records installation and networking is a major
nightmare, with many older physicians resenting the cost and hating the
input devices.

Many
physicians believe their only financial sanctuary is a closer
integration or even employment by a hospital or integrated network, and
many are bitter about a forced marriage with possibly a dysfunction
partner (physician relations with hospitals have always been tense at
best).

The
rate of change or at least the ubiquitous talk about change (ACOs,
bundling, extensive quality metrics) gets tiresome; death by meetings
and memos.

The
Medicare push to prevent hospital re-admissions has interfered with
clinical judgment and put elderly patients at risk; ditto for earlier
discharges. Nursing home and hospice work is a tiresome pain in the
butt.

The stock market is coming back, and with it physician 401(k) balances.

The
physical health of older physicians is not optimal, 30 - 40 years of
stress and sleep deprivation take a toll (consistent with my
observations over the decades).

Tuesday, March 19, 2013

I have made the point many times that if anything stops
Obamacare it will be the inability to implement an extremely complicated
program. Call it “Tom's Theory of Complexity.”

The feds have now published (link below) the draft
application for financial assistance in health care exchanges and low income
plans. Oh boy.

With attachments this could easily run 30 + pages, and of
course someone is going to have to process this (there will be an online
version). Having helped people with paperwork for nearly 40 years I can
guarantee this will be intimidating and confusing to many people.

Wednesday, March 6, 2013

One of my
non-scientific methods of gauging the current state of the health care system
is by the requests I receive for writing and editing.

For example,
I have recently received four requests to write about failed electronic medical
records systems (no surprise there).
Others include the progress of accountable care organizations (ACOs),
the future economics of physician groups, compensation models for physicians, hospital/physician
relations and new regulatory issues for nursing homes.

So all of
this gets me thinking; what could happen to create a catastrophic failure of
Obamacare? My thoughts….

Accountable
Care Organizations: ACOs could fail to work as
hoped by the feds, this could collapse the foundations of Obamacare

Failed
integration efforts: hospitals and systems are integrating multiple services,
creating much larger and much more complex organizations, not all of them will work

Thursday, February 21, 2013

Exchanges – As of today 17 states will create their own
exchange, seven states will partner with the government, and 26 states have
defaulted to the federal program (if anyone asked we would suggest defaulting
in order to let the feds do the early heavy lifting).

Perhaps the
most important questions now are:

Will any of
the exchanges be ready on time?

Will the
products be affordable?

How will
employers respond?

Employer Response – there is a great deal of discussion
but very few decisions have been announced (although some are likely in place
but not announced).

Will a generally
weak economy and slack labor market play into the decisions? Time will tell.

A strategy of
self-insuring may gain favor, and we will do a separate post on that topic.

Providers – the word heard most often is “chaos.”Providers are trying to prepare for a system
as yet poorly defined. Some trends are emerging (integration, the early ACOs)
but it is too early to tell how anything will work.

Issues in
primary care and rural health care are likely to be especially acute.

Consultants
and health care focused lawyers are raking it in – so somebody wins.

Sunday, January 13, 2013

In the past I
have predicted the EMR focus of the Obama administration might not work as well
as intended. Sadly, and many billions of dollars later, I may be correct.

(The New York
Times has run many pieces on this, the latest on the hard copy business page on
1/11/2013.)

And next year
we make the ICD-10 conversation, sort of throwing gasoline on a raging fire.

There are a
multitude of problems:

Too many
vendor systems, making EMR to EHR linkages difficult

Crazy long
and complex federal regulations

The input
devices irritate physicians and disrupt the flow of the office practice

Medicare
thinks EMRs are inflating billings, due to text cloning and auto-coding

The hospital
and nursing home systems are often distractions to nursing

Going totally
paperless is largely a myth so far

HIPAA
security issues abound

So where will
EMRs work? Based on recent observations perhaps in very large integrated
systems where every provider is on the same system, although some of the front
line personnel are singing the same sad songs as others.